Diabetes and Premature Delivery: Etiology and Risk Factors 

Avi Beigelman, Arnon Wiznitzer, Ilana Shoham-Vardi, Hilel Vardi, Gershon Holtcberg, Moshe Mazor

Depts. of Obstetrics and Gynecology and of Epidemiology and Health Services Evaluation, Soroka Medical Center and Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheba

Preterm birth is the leading cause of perinatal morbidity and mortality, while preterm labor and delivery in diabetes mellitus (DM) carries an increased risk of perinatal complications. We investigated the hypothesis that DM (gestational and pregestational) is an independent risk factor for preterm birth and evaluated the hypothesis that the risk factors for preterm birth in diabetics are different from those in non-diabetics.

The study population consisted of all singleton deliveries at this hospital between 1990-1997. Excluded were those of mothers who had not had prenatal care, or who had only partial care or multiple gestations. There were 3 subgroups: 834 women with pregestational DM, 3,841 with gestational DM, and 66,253 non-diabetics.

The combined spontaneous and induced preterm delivery rate was determined in each subgroup. Potential risk factors for spontaneous preterm deliveries were assessed by a univariate model. A logistic regression model was used to assess the unique contribution of DM (gestational and pregestational) to preterm delivery in the presence of the other risk factors, and to compare risk factors for preterm delivery between subgroups.

The prevalence of spontaneous preterm delivery was: 7.1% in non-diabetics, 10.0% in those with gestational DM and 25.5% in those with pregestational DM. When adjusted by a multivariate model for other risk factors for preterm delivery, DM still remained an independent risk factor for spontaneous preterm delivery (gestational DM: odds ratio 1.28, 95% CI: 1.1-1.48; pregestational diabetes: odds ratio 3.4, 95% CI: 2.65-4.36).

The main difference in risk factors for preterm birth between the 3 subgroups was the amount of amniotic fluid. Polyhydramnios was an independent risk factor for preterm delivery in non-diabetics and in pregestational DM, but not in gestational DM. On the other hand, oligohydramnios was associated with a higher risk for preterm delivery only in gestational DM compared to non-diabetics.

DM (gestational and pregestational) is an independent risk factor for spontaneous preterm delivery. Polyhydramnios is an independent risk factor for preterm delivery in pregestational but not in gestational DM. Oligohydramnios is a greater risk factor for preterm delivery in gestational DM compared to non-diabetics.

Current Trends in Surgery for Female Urinary Stress Incontinence 

M. Neuman, A. Musaiev, Y.Z. Diamant

Dept. of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem

Quality of life of 5% of the female population is impaired by urinary stress incontinence. Its cause is pelvic floor relaxation and the cure is surgical. The most widely performed operations are retropubic colposuspensions and sling operations, which have relatively high, well-proven cure rates. Yet because of the long rehabilitation required, gyneco-urologists seek minimally invasive ways to solve the problem.

Vaginal colporrhaphy and laparoscopic operations are not common, but the recently reported TVT might become popular if proven effective.

Sublingual Immunotherapy for Allergic Diseases

David Nelken

Medical Building, Sprinzak St., Tel Aviv

4 patients suffering from severe pollinosis and/or allergic rhinitis, with or without asthma, were treated as follows: 30 minutes before breakfast the vaccine was dropped sublingually and retained for 2-3 minutes before being swallowed. It was a commercial preparation of allergen, diluted 50% w/v in glycerin.

This stock solution was then diluted in physiological saline containing 0.05% human albumin and kept refrigerated in a dark glass bottle for up to 4 weeks. Of the first dilution which contained 10 Au/ml, 1 drop was given on day 1 and 1 drop more each day until days 5 to 17, when 5 drops were given daily. Then 1000 and then 2500 Au/ml were given sequentially in the same manner, and finally 5000 was given for up to 2 years. A maintenance dose of 3 drops of 5000 Au/ml twice weekly was then prescribed.

41 patients showed striking clinical improvement after about 6 months of treatment. A definite reduction in the use of other medications was achieved in all. Sublingual immunotherapy is practically free of unwanted side effects and easy to self-administer at home.

To establish the specificity of sublingual immunotherapy, patients who had severe allergic symptoms to one pollen allergen causing symptoms in the spring and to a second in the autumn, were first immunized sublingually against a single allergen. A year later, after symptoms due to this allergen had subsided, and if symptoms caused by the second allergen had not improved, immunization against the second allergen was started.

Sublingual immunotherapy acts by increasing mucosal antibodies at the site of entry of the allergen into the respiratory tract. It is a safe and practical procedure with results comparable to subcutaneous allergy injections.

Breast Tumors Demonstrated by Tc-99m Sestamibi Scintimammography 

Itzhak Pappo, Tifha Horne, Herbert Merdad, Ruben Orda

Dept. of Surgery A, Institute of Nuclear Medicine and Dept. of Pathology, Assaf Harofeh Medical Center, Zrifin; and Sackler Faculty of Medicine, Tel Aviv University

Breast cancer can be detected by scintimammography using Tc-99m sestamibi (MIBI). The method is highly accurate, sensitive and specific. Histologically, most of the tumors have been adenocarcinomas.

We present 2 women with rare breast tumors, primary squamous cell carcinoma and malignant phyllodes tumor. In both, mammography and cytological biopsy were not diagnostic, but MIBI scintimammography demonstrated focal uptake in the diseased breast.

Giant Lesions in Multiple Sclerosis: A Diagnostic Challenge 

Bruria Shalmon, Dvora Nass, Zvi Ram, Anat Achiron

Institute of Pathology, Neurosurgery Dept. and Neuroimmunology Unit, Sheba Medical Center, Tel Hashomer

Multiple sclerosis is the most common demyelinating disease of the central nervous system affecting young adults, in which destruction of the axon myelin sheath disturbs signal transduction. The disease course is usually remitting and relapsing, but sometimes there is steady neurological deterioration.

The diagnosis depends mainly on an adequate clinical history and neurological examination. Evoked potentials, elevated cerebrospinal fluid gamma globulin with oligoclonal bands, and imaging studies, mainly magnetic resonance imaging (MRI), also contribute to the diagnosis.

Multiple sclerosis may occasionally present as a mass lesion that clinically and radiologically is indistinguishable from a brain tumor. We present 2 cases of giant tumefactive lesions, proven by brain biopsy to be of demyelinating nature.

Thrombolytic Therapy or Primary Coronary Angioplasty in Acute Myocardial Infarction?

David Pereg, Shlomo Behar, Alexander Battler, Valentina Boyko, Shmuel Gottlieb, Jonathan Leor: Israel Thrombolytic Survey Group

Cardiology Division, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba; Neufeld Cardiac Research Institute, Tel Hashomer and Tel Aviv University; and Cardiology Dept., Rabin Medical Center, Petah Tikva

There has been continuous debate over the superiority of primary percutaneous, transluminal, coronary angioplasty (PTCA) over thrombolysis for acute myocardial infarction (AMI). It was questioned whether this advantage of primary PTCA reported in selected populations by experienced centers can be replicated in our clinical practice.

We compared demographic and clinical variables, therapies and outcome in AMI treated with primary PTCA vs thrombolytic therapy. Clinical and demographic variables of 1,678 unselected AMI patients (admitted January/February and May/July 1996) were analyzed in 16 cardiac care units with on-site catheterization facilities and ability to perform PTCA. Of these 803 (48%) were treated by thrombolysis and 99 (6%) by primary PTCA.

The prevalence of adverse prognostic variables, such as anterior wall MI, heart failure on admission or during hospital stay, pulmonary edema, and ventricular tachycardia or fibrillation, was higher in the PTCA group. The 7-day, 30-day and 1-year mortality rates were similar in the 2 groups: 4%, 7.2% and 12.8%, respectively, in the PTCA group and 5%, 7.2% and 11.1% in the thrombolysis group. There was a trend toward lower mortality in subgroups of high-risk patients: those with heart failure on admission (Killip class >1), the elderly (>65 years), and those with previous MI treated with PTCA. After adjusting for confounders, treatment with primary PTCA was not found to be associated with lower mortality.

Only a small proportion of AMI patients in Israel were treated with primary PTCA in 1996. The frequency of adverse prognostic factors among them was higher but their short and long term outcomes were similar to those of high risk patients treated with thrombolysis.

Tuberculous Meningitis in Review

Mozes Toledo, Y. Skurnik, A. Razabek, Z. Stoeger

Medical Dept. B, Kaplan Medical Center, Rehovot, (Affiliated with Hebrew University-Hadassah Medical School, Jerusalem)

Tuberculosis meningitis is one of the most dangerous forms of tuberculosis (TB). Due to large waves of immigration, the incidence of TB in Israel has increased in recent years, as has that of TB meningitis. Due to its high mortality, rapid diagnosis of TB meningitis is of paramount importance.

We present a patient admitted with a acute febrile disease which was subsequently diagnosed as TB meningitis.

The Decision-Making Process of Abortion High Committees 

Raphael Cohen-Almagor, Yehuda Snir

Faculty of Law, University of Haifa

Factors influencing the decision-making process of the Abortions High Committees (after the 23rd week of pregnancy), and whether there are differences between decisions of different Committees were examined. A questionnaire was sent to the 45 members of these committees of whom 24 responded (53%). Some hospitals refused to cooperate because they did not want to evoke discussion about the practices of the Committees.

The significant factors that play a part in the decision as to whether or not to allow an abortion are the medical condition of the fetus, the medical and psychological state of the mother, and the week of pregnancy. The data also show that women committee members are more inclined to authorize abortion than men, and that the more religious members are less inclined to authorize abortions. No differences were found between hospitals, and the age of committee members had no influence. Members did not accord any importance to fear of litigation in their considerations.

Drug Abuse among Patients Requiring Psychiatric Hospitalization 

Gregory Katz, Emi Shufman, Haim Y. Knobler, Mark Joffe, Rachel Bar-Hamburger, Rimona Durst

Kfar Shaul Mental Health Center, (Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem); and Jerusalem Institute for Treatment of Substance Abuse, Israel Antidrug Authority

We assessed the incidence of drug abuse among patients requiring psychiatric hospitalization, and characterized the population at risk. The data on drug abuse were obtained from self-reports and urine tests in 103 patients, aged 18-65, hospitalized in the Kfar Shaul Psychiatric Hospital (autumn 1998).

There was close correspondence between the self-reports and the results obtained from urine tests. 1/3 admitted to having used illegal drugs and signs of drug abuse were found in about 1/4 of the urine tests. The most prevalent drugs were cannabis products (hashish and/or marijuana) and in 15 patients opiates.

Drug users were younger than non-users. With regard to psychiatric symptomatology, fewer negative symptoms were recorded among cannabis abusers with schizophrenia, compared to schizophrenic patients with no history, past or present, of cannabis abuse.

The present findings confirm the clinical impression that there has been an increase in drug abuse among mental patients, parallel to that found in society at large. Confirmatory surveys are necessary. Our findings clearly suggest that a change in attitude has occurred in Israel to what has been considered a marginal problem. Hospitalized mentally-ill patients, the younger in particular, should be considered at risk for drug abuse.

Physicians' Reminders Promote Annual Fecal Occult Bloodtesting Compliance

Shlomo Vinker, Vardina Shumla, Eliezer Kitai

Family Medicine Dept., Sackler Faculty of Medicine, Tel Aviv University

Screening for the early detection of colorectal cancer using the fecal occult blood test has been shown to be effective in reducing mortality. In Israel family physicians recommend that their patients, aged 50-75, have the test performed annually. But compliance with testing in the general population has been poor.

We therefore studied this issue in 3 primary care facilities, in 384 patients, average age 62.7‏6.9 years; 81 (21.1%) performed the fecal occult blood test. Performance rates were significantly lower (13.9%) in those aged 50-59 (p = 0.0003), as compared wh those aged 60-69 and 70-75 (24.3% and 24.7%, respectively). Compliance rates of the patients of different physicians varied as well.

Recommendation of family physicians led to overall compliance of 21.1%. Additional efforts are needed to increase compliance in order to decrease colorectal cancer morbidity and mortality in Israel.

Benign Paroxysmal Positional Vertigo: Diagnostic Pitfalls 

C.R. Gordon, O. Zur, R. Furas, E. Kott, N. Gadoth

Depts. of Neurology and of Physical Therapy, Meir General Hospital, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University

Benign paroxysmal positional vertigo (BPPV) is a common but often unrecognized cause of treatable vertigo. Possible causes of misdiagnosis of BPPV were studied by review of the records of 191 patients referred to our neurology clinic; 36 were identified as having BPPV not previously diagnosed. On referral the patients carried the following diagnoses: unspecified dizziness/vertigo (33%), transient ischemic attacks (28%), cervicogenic vertigo (19%), psychogenic dizziness/vertigo (11%), and others (8%).

The paroxysmal nature of the vertigo and position-precipitating factors were not spontaneously reported by 31%. Atypical, even bizarre, symptoms including dizzy sensations were reported by 19%, and neck pain and headache were cardinal symptoms that accompanied vertigo.

The Dix-Hallpike maneuver, which is essential for the diagnosis of BPPV, was not performed in any of the patients prior to referral. 30 (83%) experienced complete resolution of signs and symptoms after the first physical treatment session.

We conclude that non-paroxysmal, non-positional vertigo does not rule out BPPV. Atypical and even bizarre complaints of dizziness, as well as neck pain and headache could be cardinal symptoms of BPPV. The Dix-Hallpike maneuver is mandatory in those complaining of dizziness and vertigo.

Aortopexy for Tracheomalacia in Infants and Children

I. Vinograd, B. Klin, A. Silbiger, G. Eshel

Depts. of Pediatric Surgery, and Anesthesia, Dana Children's Hospital, Sourasky-Tel Aviv Medical Center;  Dept. of Pediatric Surgery and Intensive Care Unit, Assaf Harofeh Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

During the past 12 years (1985-1998), 28 infants and children were operated on here for tracheomalacia. The diagnosis was made in all using rigid bronchoscopy. During the examination the infants breathed spontaneously, but the trachea collapsed on forced expiration.

Indications for surgery were repeated cyanotic spells ("dying spells") in 22, recurrent pneumonia, and inability to extubate (in 8). In 11 there were more than 1 indications. Age at surgery was from 7 days to 3 years (average 11.7 months).

All 28 children underwent bronchoscopy and guided aortopexy via a left-third intercostal approach. The ascending aorta and aortic arch (and in 6 the proximal innominate artery as well) were lifted anteriorly, using 3-5 non-absorbable sutures (5.0). The sutures were placed through the adventitia of the great vessels and then passed through the sternum.

Respiratory distress was significantly improved in 21. Another 2 required external tracheal stenting with autologous rib grafts, and in 1 other an internal Palmaz stent was introduced for tracheal stability. In 4 aortopexy failed, 1 of whom had tracheobronchomalacia throughout, and another 3 had laryngomalacia which required tracheostomy to relieve the respiratory symptoms.

Postoperative complications were minor: pericardial effusion in 1 and relaxation of the left diaphragm in another. 1 infant subsequently died, of unknown cause 10 days after operation, after having been extubated on the 1st postoperative day. On long-term follow-up (6 months to 12 years) 25 were found free of residual respiratory symptoms and 3 remained with a tracheostomy.

Thus, infants and children with severe tracheomalacia associated with severe respiratory symptoms, can be relieved by bronchoscopic guided suspension of the aortic arch to the sternum.

Prolonged Neuromuscular Damage following Cortico-Steroids and Muscle-Relaxants

Yehonatan Sharabi, Eran Segal, Ehud Grossman

Dept. of Medicine D and ICU, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Many patients mechanically ventilated for acute respiratory failure, are treated with medication that includes a combination of cortico-steroids and non-depolarizing neuromuscular-blocking agents (NNBa). A third of them can be expected to develop delayed neuromuscular damage, which may be severe and prolonged.

We describe a 50-year-old man who suffered from acute myeloid leukemia and was ventilated due to pneumonia. He was treated with pancuronium and cortico-steroids, and during recovery suffered quadriparesis that lasted several months.

Typically this damage is purely motor and is accompanied by absent tendon-reflexes, sometimes with elevated creatin-kinase. Muscle biopsy usually shows deletion and degeneration of thick myosin filaments. The phenomenon is related to the duration of NNBa treatment, and probably results from an adverse synergistic effect on muscle tissue of the cortico-steroids and cortico-steroid-like NNBa given the immobilized patient.

Awareness of this adverse effect of steroids and pancuronium, the use of passive mobilization, shortening the use of NNBa and early rehabilitation would minimize disability due to this phenomenon.

Minocycline Pneumonitis and Eosinophilia

Noam Fink, Meir Mouallem

Dept. of Medicine E, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University

Pneumonitis with eosinophilia is one of the less common and severe adverse effects of minocycline. The disease evolves in days or weeks from the beginning of treatment, and is usually characterized by dyspnea, fever and bilateral infiltrates in the chest X-ray. With cessation of the antibiotic, and sometimes adding cortico-steroids, clinical and roentgenological resolution follow.

We present a case given minocycline for folliculitis and 3 weeks later fever, cough and shortness of breath developed. The clinical and roentgenological course was consistent with minocycline pneumonitis accompanied by eosinophilia.

רונית חיימוב-קוכמן¹, ראובן ברומיקר², אריאל מילויצקי¹

¹מחלקת נשים ויולדות ²והמחלקה לטיפול נמרץ בילוד, בי"ח הדסה הר הצופים, הפקולטה לרפואה, האוניברסיטה העברית, ירושלים